For Kids, How Short Is Too Short?

Anisha Patel, DO, plays with pediatric patients in the waiting area of One Long Wharf, where children come for stature assessment.

Credit: Robert A. Lisak

No parent likes to see a child in pain, whether physical or psychological. For parents of children diagnosed with short stature, the biggest concern is the emotional toll on their loved ones.

According to the U.S. Food and Drug Administration, short stature means an estimated final height below 5 feet 3 inches for boys or 4 feet 11 inches for girls. The average height in the United States is 5 feet 8 inches for men and 5 feet 4 inches for women. While no two children are affected the same way, children who are shorter than peers may be exposed to name-calling and excluded from social groups.

One huge downside is that we don’t have long-term data, beyond 30 years, about its (hormone treatment's) effects on people.

Anisha Patel, DO

“The common complaints I hear are about kids picking on them at school—bullying them about their height—or about how sports are difficult because there’s an obvious height difference,” says Anisha Patel, DO, a Yale Medicine pediatric endocrinologist who works with kids who have been diagnosed with short stature. “Though sometimes it can come at home, where a younger sibling is taller, or is the same height.”

Sometimes a child is perfectly comfortable with his or her height. When she sees patients, Dr. Patel makes sure to ask the child if height is a concern or something that has been on the child’s mind.

“If they’re well adjusted and don’t care about their height, I may not even end up seeing them again,” she says, “since they’re less likely to seek treatment than someone who’s extremely depressed and becomes introverted because of height concerns.”

Causes of short stature

Because growth can be forecast based on the heights of a child’s parents, when a child falls off his projected trajectory and is found to have short stature, a doctor will try to determine what else may be at play. Underlying causes can include medical reasons, genetics (many genes are involved in height) or constitutional delay, which describes children who are often referred to as “late bloomers.” Puberty normally begins at about 10 for girls and 11 for boys and generally is complete by the time a child is 16. But for some children, it starts later.

“Constitutional delay basically means that you’re 14 years old, but your bones are maybe around 11,” Dr. Patel says, adding that an X-ray of the left hand, called a bone age, can help determine the age of one’s bones. “So even though your peers are going through all the pubertal changes, you’re not. You are going to get there, but you’re going to get there a few years later.”

Treatment options

Anisa Patel, DO, advises many parents to wait rather than quickly seek treatment

Dr. Patel sees a lot of patients with constitutional delay. One option, she says, is to wait it out. But for children who may be feeling the brunt of bullying, she sometimes recommends treatment with a low dose of testosterone, which can help to induce puberty, and growth, a bit earlier.

For children whose short stature has an underlying medical reason, the course of treatment may lead to a tough choice for families: Should the child take growth hormones? These hormones stimulate growth, cell reproduction and cell regeneration.

Growth hormones are relatively new for treating short stature, so one of the main considerations for families is what it will do to the child’s body beyond potentially encouraging growth.

“One huge downside is that we don’t have long-term data, beyond 30 years, about its effects on people,” says Dr. Patel, who is also an assistant professor of pediatrics at Yale School of Medicine.

Another important factor in the decision is the treatment application, which involves a daily injection and regular doctor visits to monitor the body’s reaction. If, after a trial period of up to one year, the treatment seems to be having an effect on growth, the treatment may continue through the end of puberty, meaning that a child may need daily injections for several years.

Then there is the cost. The price of growth hormone treatment can vary, but it is expensive, potentially costing tens of thousands of dollars per year and requiring prolonged negotiations with an insurance provider.

“It is a huge thing,” Dr. Patel says. “And on top of everything, the family may have to deal with a lot of appeals and just being persistent with the insurance company to get approvals for treatment.”

It is a lot to weigh, particularly because a child who undergoes growth hormone treatment may not grow to a desired height, depending on the cause. For idiopathic short stature (meaning there is no underlying cause), three to four years of treatment may result in a height increase of just 2 to 4 inches. That may still be important to a family. Indeed, Dr. Patel says she sees some children who are not even diagnosed with short stature.

“I’ve had to turn down patients because they just want to improve their final height,” she says. “If you’re predicted to be 5 feet 8 inches, which is the male average for the country, but you want to be 5 feet 10 inches, then aside from it not being the approved use for growth hormones, the benefit is not worth the risks.”

Societal beliefs about height can play a role for some in deciding on treatment. Bullying aside, many parents may be thinking about the child’s future when considering treatments to improve final height. Will being short affect their child’s earning potential, romantic opportunities or overall happiness? Many studies and polls find various and opposing opinions on those outcomes.

For people of any height, quality of life often comes down to self-esteem. In the end, emotional support may be the best thing a parent can provide, whether or not the child ends up getting treatment.

To learn more about how we handle concerns about short stature, click here.